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Perfect for patient education.
There are two main categories of reconstruction procedures: breast implant and natural tissue breast reconstruction.
Breast implant involves insertion of a prosthesis made of synthetic material. A typical breast implant has a silicone shell and is filled with saline or silicone gel.
Natural Tissue Breast Reconstruction Surgeries use the body's own tissue for the new breast. In this type of procedure, a flap - a section of skin, fat, and possibly muscle - is harvested from a donor site elsewhere in the body and transferred to the chest to make the new breast. Possible tissue donor sites include: lower abdomen, back, buttock and inner thigh. The lower abdomen is by far the preferred donor site as it comes with a bonus of a flatter tummy after operation. The use of autologous tissue allows the reconstruction of a breast which looks and feels most like a normal breast. More importantly, this also solves the problem of the new breast being rejected by the body's immune system. However, compared to breast implant, natural tissue reconstruction requires longer initial hospital stay. It also results in additional scar and possible weakening of the donor site due to loss of muscle.
The technique of natural tissue breast reconstruction has evolved significantly over time.
The first of all natural tissue reconstruction procedures is the Transverse Rectus Abdominus Myocutaneous flap – or TRAM flap. In the original technique, called the pedicled TRAM flap, a section of skin and fat attached to a piece of the rectus abdominis muscle – the six-pack muscle - is cut from the lower abdomen. The flap remains attached to the body by the piece of muscle. The flap is then rotated together with the muscle and passed under the skin to the new location in the chest. Here, it is shaped to form the new breast. The new breast is supplied by the blood vessels that run inside the rectus abdominis muscle. A piece of synthetic mesh is placed in the abdomen to provide support for the abdominal wall. The disadvantages of this technique include weakening of the abdominal wall due to significant loss of muscle. Tethering of the flap to the body also makes it harder to be configured into the desired shape.
Free TRAM Flap is an improvement from the original technique. In this procedure, a section of skin, fat and part of the rectus abdominis muscle with blood vessels within it, is separated COMPLETELY from the body and transferred to the breast location. The blood vessels of the flap – the deep inferior epigastric artery and vein - are connected to recipient blood vessels in the breast using microsurgery techniques. Free flaps are easier to sculpt into the desired shape. Blood supply to the new breast is also more robust this way. However, this technique requires microsurgery expertise and therefore is not offered by many surgeons. The amount of muscle loss from the abdomen remains significant.
Deep Inferior Epigastric Perforator flap, or DIEP flap, is a significant advancement from TRAM flaps. In this procedure, the blood vessels – the deep inferior epigastric artery and vein - are meticulously dissected from the abdominal muscle. While an incision is made in the rectus abdominis for this purpose, NO muscle is removed. The blood vessels of the flap are then connected to the recipient vessels in the breast using microsurgery. Because no muscle is lost from the abdomen, the abdominal wall is NOT weakened after a DIEP flap procedure.
Another procedure – the SIEA flap - is based on a different set of blood vessels - the Superficial Inferior Epigastric Artery and Vein. These vessels supply the skin and fat tissue of the abdomen and run within the fat layer. With this flap, the abdominal muscle is left untouched. This is therefore the preferred technique whenever it is possible. The reason why this is not more widely used is because these vessels are not large enough in 90% of patients. Commonly, these superficial blood vessels are approached first during surgery. If they are big enough, a SIEA flap will be used, if not, a DIEP flap will be performed instead.